The rheumatoid arthritis patient in the clinic: comparing more than 1300 consecutive DMARD courses

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Rheumatology 2002; 41: 1367-1374

© 2002 British Society for Rheumatology

The rheumatoid arthritis patient in the clinic: comparing more than 1300

consecutive DMARD courses

D. Aletaha and J. S. Smolen1,

Division of Rheumatology, Department of Internal Medicine III, University of

Vienna and

1 Second Department of Medicine, Lainz Hospital, Vienna, Austria

Background. Therapy of rheumatoid arthritis (RA) is typically characterized

by the sequential use of disease-modifying anti-rheumatic drugs (DMARDs).

This study aimed to reveal treatment patterns with traditional DMARDs and

their changes during the two decades before the recent introduction of new

DMARDs.

Methods. A total of 593 RA patients were followed from their first

presentation to our clinic throughout the course of their disease; 222

patients received their first DMARD therapy while under our care. More than

2300 patient years of therapy were analysed for the efficacy [using

C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) as

surrogates] and duration of drug therapy of consecutive DMARDs.

Results. Before 1985, 65­90% of initial DMARDs were gold compounds, but

their use decreased continuously thereafter. Antimalarial (AM) drugs were

important initial DMARDs in new patients at all times, whereas

sulphasalazine (SSZ) and methotrexate (MTX) gained increasing significance

after 1985 (the first DMARD was MTX in up to 29% of new patients).

Penicillamine (DPA), azathioprine (AZP), cyclosporin (CyA) and combination

therapies were not usually employed initially, but were reserved for the

later course of the disease. Gender, age and rheumatoid factor were not

different between patients receiving different DMARDs. The baseline

acute-phase response was higher in patients treated with MTX (mean CRP 3.5

mg/dl) than in those treated with SSZ (CRP 2.4 mg/dl; P < 0.05) or AM (CRP

2.1 mg/dl; P < 0.05), suggesting that MTX was used preferentially in

patients with high disease activity. On the other hand, once AM or SSZ had

been discontinued, MTX was the most common subsequent DMARD (in 31 and 56%

respectively). Comparison of first DMARDs with subsequent ones revealed that

first DMARDs were more effective: the acute-phase response decreased most

prominently during first therapies (CRP reduction was 1.28 mg/dl during

first courses and 0.35 mg/dl during fourth or later courses; P < 0.01); and

retention rates were significantly longer for first compared with subsequent

therapies (median of 24.5 months for first and 18.6 months for fourth or

subsequent therapies; P < 0.001).

Conclusion. MTX was the most commonly employed DMARD therapy for RA and was

used increasingly as first therapy in newly diagnosed RA. Patients with high

disease activity were given MTX therapy more often than other DMARDs, while

those with low activity were more likely to receive SSZ or AM, and MTX on

failure of these drugs. First DMARDs in new patients were retained longer

than subsequent DMARDs, apparently because they are more effective.

KEY WORDS: Rheumatoid arthritis, First DMARD, Consecutive DMARD, Efficacy.